25 if LDL is above goal. ⇒ A 3 month trial of TLC appropriate unless LDL ≥ 220 Consider adding drug therapy if LDL exceeds goal for patient ⇒ If CHD equivalent may start drug right away, lower risk can try 3 months trial TLC first Identify metabolic syndrome and treat, if present, after 3 months of TLC. Treat elevated triglycerides as per ATP III algorithm on page 3.
MONITORING ♦
Patients on TLC only should have a repeat lipid panel 3 months after TLC initiation.
♦
After the initial follow-up visit, patients may be seen at 3 month intervals until target LDL goal is reached.
♦
Check LFTs as clinically indicated, usually check 3 mos after reaching maximum statin dose. If LFTs increase, monitor until normalize, if consistently > 3X normal- stop statin.
♦
Once at goal, lipids and LFTs should be monitored at 6-12 month intervals.
♦
If a patient has achieved treatment goals and is clinically stable on at least 2 consecutive encounters , the patient may be reevaluated every 180 days unless the PCP determines the patient needs more frequent monitoring.
Information contained in the guidelines is not a substitute for a health care professional's clinical judgment. Evaluation and treatment should be tailored to the individual patient and the clinical circumstances. Furthermore, using this information will not guarantee a specific outcome for each patient.
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CPHCS Care Guide: Hyperlipidemia
March 2011
SUMMARY
DECISION SUPPORT
PATIENT EDUCATION/SELF MANAGEMENT
MEDICATIONS: DRUG CLASS HMG COA REDUCTASE INHIBITORS
LIPID/LIPOPROTEIN EFFECTS
AGENTS AND DAILY DOSES First line: Simvastatin (Zocor) (20-80 mg) (20 mg lowers LDL average 35%)
As a class:
Second Line: Atorvastatin+ (Lipitor) (10-80 mg) (20 mg lowers LDL average of 46%) (+ Will be generic in late 2011 currently nonformulary)
LDL-C
18-55%
HDL-C
5-15%
TG
7-30%
(STATINS)
SIDE EFFECTS Myopathy Increased liver enzymes
Special Indication: Pravastatin (Pravachol) (20-40 mg) (20 mg lowers LDL average of 24%) This is drug of choice if patient on protease inhibitor or other strong CYP34A inhibitor
Use fibrates and niacin with caution
Cholestyramine (4-16 g)
LDL-C
15-30%
HDL-C 3-5% TG No change or increase
NICOTINIC ACID
FIBRIC ACIDS
Absolute: Active or chronic liver disease Pregnancy
Drug interactions: Statins (except pravastatin and rosuvastatin) are metabolized by cytochrome P-450 34A (CYP34A)–so do not give most statins (except pravastatin) with drugs that block CYP34A including: • Protease inhibitors • Macrolide antibiotics • Some anti-fungals • Cyclosporine
Rosuvastatin* (Crestor) (10-40 mg) (20 mg lowers LDL average of 52%) ( * Formulary ($$$) - must have failed 12 wks max dose Simvastatin)
